How to Write a Treatment Summary for Transfer of Care

What Is a Treatment Summary for Transfer of Care?

A treatment summary for transfer of care is a clinical document that communicates essential information about a client's treatment history, current clinical status, and ongoing needs to a new provider. It serves as the bridge between the terminating therapeutic relationship and the beginning of a new one, ensuring continuity of care and preventing the loss of clinical progress during transitions.

Transfer of care occurs for many reasons: a client relocates, changes insurance, graduates from a training clinic, or seeks a different treatment approach. Whatever the reason, the outgoing clinician has an ethical obligation — articulated in the APA Ethics Code (Standard 3.12) and parallel standards across mental health disciplines — to facilitate a smooth transition. The treatment summary is the primary instrument for fulfilling this obligation.

A well-written treatment summary saves the receiving clinician time, protects the client from having to retell their entire history, and ensures that critical information — current medications, risk factors, treatment gains, and specific recommendations — is not lost in the transition. A poorly written or absent treatment summary forces the new provider to start from scratch and puts the client at risk of discontinuity, duplicated efforts, or missed safety concerns.

When You Need It

• When a client is transferring to a new therapist due to relocation, insurance change, or clinician departure
• When a client is stepping up or stepping down to a different level of care (outpatient to intensive outpatient, inpatient to outpatient)
• When a trainee is leaving a practicum or internship site and transferring clients to other clinicians
• When a client is being referred to a specialist (e.g., from generalist therapy to an eating disorder specialist)
• When treatment is ending and a discharge summary is required by agency policy or accreditation standards
• When a client requests a copy of their treatment records and you want to provide a coherent summary rather than raw notes

Key Components

Client Identifying Information

Client name, date of birth, contact information, and emergency contact. Include the dates of treatment (start and end) and the total number of sessions.

Referral Information

Who referred the client originally, why the transfer is occurring, and the receiving provider's name and contact information (if known).

Diagnoses

Current DSM-5-TR diagnoses with ICD-10 codes. Note any diagnostic changes that occurred during treatment and the reasoning behind them. If a diagnosis was considered and ruled out, include that as well — it prevents the next clinician from re-evaluating conditions you have already addressed.

Presenting Problem and Treatment History

A concise summary of what brought the client to treatment, their initial clinical picture (including baseline outcome measure scores), and any relevant psychiatric, medical, substance use, and social history. This should be briefer than the original assessment — focus on the information the receiving clinician needs to understand the clinical picture.

Treatment Provided

The modality, frequency, and duration of treatment. Describe the primary therapeutic approaches used (CBT, EMDR, DBT skills, psychodynamic psychotherapy, etc.), the specific interventions that were most effective, and any approaches that were attempted but not helpful. Include medication management if you coordinated with a prescriber.

Treatment Progress and Outcomes

Document the client's progress with specific reference to treatment goals. Include outcome measure data with scores at intake, during treatment, and at the time of transfer. Describe functional changes — improvements in relationships, work, daily living, or other areas identified in the treatment plan.

Current Clinical Status

A snapshot of the client's functioning at the time of transfer. This includes current symptom severity, current medications and prescribers, current risk status (suicidal ideation, self-harm, substance use), and the client's subjective assessment of their current functioning.

Risk Assessment

Current risk level with supporting data. If the client has a history of suicidal ideation, self-harm, or suicide attempts, provide specific details — the receiving clinician must have this information from the outset. Include the current safety plan if one exists.

Recommendations for Continued Treatment

Specific, actionable recommendations for the receiving clinician. These should include recommended treatment modality and frequency, areas that still need clinical attention, potential treatment challenges the new clinician should anticipate, and any contraindications or approaches that were not effective.

Medications and Prescriber Information

A current medication list with dosages, prescribing provider names and contact information, and any relevant medication history (medications tried and discontinued, reasons for changes, adherence concerns).

How to Write It Step by Step

Step 1: Begin preparation two to four sessions before the final session. Inform the client that you will be preparing a treatment summary and discuss what it will contain. Administer final outcome measures so you have endpoint data. Ask the client if there is anything they want communicated to the new provider.

Step 2: Obtain a signed Release of Information. Before sending any information to the receiving clinician, ensure the client has signed a valid authorization specifying the recipient, the information to be released, and the purpose. Retain the signed form in the record.

Step 3: Write the summary using the structure above. Begin with diagnoses and presenting problem, then summarize treatment provided, progress, current status, risk assessment, and recommendations. Reference outcome measure scores to quantify progress. Be concise — the receiving clinician needs a clear picture, not a complete transcript.

Step 4: Focus recommendations on actionable specifics. Rather than "continue therapy," specify "continue individual therapy using cognitive approaches targeting residual safety and trust beliefs, with PCL-5 monitoring every 4-6 sessions." Specific recommendations give the receiving clinician a running start.

Step 5: Address risk explicitly. Even if the client's risk level is low, document the assessment. The receiving clinician must know from the outset whether there is a history of suicidal ideation, self-harm, or other safety concerns. Err on the side of providing too much risk information rather than too little.

Step 6: Review the summary with the client. Before sending, review the summary with the client. This supports transparency, allows the client to correct any factual errors, and can be a meaningful part of the termination process. Some clients find it validating to see their progress documented.

Step 7: Send the summary and document the transfer. Send the summary to the receiving clinician using a secure method (encrypted email, secure fax, or direct mail). Document in the client's chart that the summary was sent, the date, the method of transmission, and the recipient.

Common Mistakes

1. Sending raw session notes instead of a summary. A receiving clinician does not need — or want — 30 pages of progress notes. They need a synthesized, clinically focused document that communicates the essential picture in two to four pages. Session notes are part of the record; they are not a treatment summary.

2. Omitting outcome measure data. Writing "client improved" without quantitative data is vague and unhelpful. Include baseline and endpoint scores on standardized measures so the receiving clinician has objective benchmarks and can track ongoing progress against a documented trajectory.

3. Providing vague recommendations. "Continue treatment" is not a recommendation — it is a platitude. Recommendations should specify modality, focus areas, potential challenges, monitoring tools, and any contraindications. The more specific the recommendations, the smoother the transition.

4. Forgetting to address medications and prescriber coordination. If the client is on psychotropic medication, the treatment summary must include the current medication list, dosages, prescribing provider contact information, and any relevant medication history. A client who transfers to a new therapist without prescriber coordination risks gaps in medication management.

5. Not documenting the transfer in your own records. After sending the treatment summary, document the transfer in the client's chart — the date of the last session, the reason for transfer, the name of the receiving provider, and confirmation that the summary and ROI were sent. This closes the clinical record appropriately and protects you in case of future questions about the transfer.